Every finding on record at Betty Ann Nursing Center

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to the health department within the required 2-hour timeframe for 1 (#1) of 4 sampled residents reviewed for abuse.The DON reported the facility census was 53.Findings:An admission record, dated 08/06/25, showed Res #1 had diagnoses which included aphasia and weakness.A social service note, dated 08/20/25 at 11:44 a.m., showed Res #1 had signed the room change agreement form and moved from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B.An Incident Report Form, dated 08/20/25, showed Res #1 reported they had been sexually abused by another resident. The inbound notification notation on the report showed it had been received by the health department on 08/20/25 at 5:23 p.m. The report showed local law enforcement was notified of the allegation on 08/20/25 at 1:40 p.m., and the facility began an investigation. The incident report showed that Res #1 had been moved to a different room on another hall for safety. On 09/03/25 at 9:30 a.m., registered nurse #1 stated allegations of abuse should be reported to administration as soon as possible because they were required to make a report to the health department within two hours.On 09/03/25 at 10:55 a.m., the DON stated they were unsure what time the allegation was made, but agreed more than two hours had elapsed between the allegation and sending the initial report to the health department.

On 05/08/25, an Immediate Jeopardy (IJ) was determined to exist related to the facility's failure to protect residents from abuse. The failure resulted in nine physical assaults by Res #2 on eight other residents between 01/03/25 and 05/01/25. On 05/08/25 at 5:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 05/08/25 at 6:04 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template. On 05/09/25 at 9:06 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, 1. Resident # [2] is currently in inpatient psychiatric facility, [name withheld]. [NAME] Nursing Center is working with [name withheld] to find alternate placement for resident other than this facility. If alternative placement cannot be arranged prior to discharge, resident will return to [NAME] nursing center where [they] will remain under supervision of staff until other placement is found. Resident will have direct supervision when in close proximity to other residents and behaviors will be addressed immediately by staff for the safety of all residents. Date of Compliance: pending resident discharge to facility 2. Residents who have been or may have been affected include resident numbers 9, 2, 4, 5, 3, 6, 7, 8, 1, and other residents residing in the facility at the time of the incidents. DON/ADON/ADMIN [administrator]/Designee have reviewed resident records and care plans to identify residents with increased needs for monitoring, interventions or clinical follow up for new or increased behaviors. They will ensure care plans and assessments are updated to current resident status and follow up routinely. Date of Compliance: 5/10/25 12 noon 3.Training Administrator, Director of Nursing, Assistant Director of Nursing and nursing staff will be provided training by GeriPsych Nurse Practitioner on 5/9/25 over: Recognizing behavior changes and triggers Interventions for redirection and de-escalation of aggressive or inappropriate behaviors. Documentation of behaviors and interventions Date of Compliance: 5/9/25 11:59 pm Administrator, Director of Nursing, ADON, MDS will be inserviced on 5/9/25 Incident reporting process, including timeliness of reporting, notification of necessary parties, documentation of notifications, immediate on ongoing interventions. Routine review of daily documentation and risk management reports to ensure timely reporting and follow-up of incidents, behaviors or other resident concerns. Date of Compliance: 5/9/25 11:59 pm On 5/9/25 Facility staff, including nursing staff, and ancillary staff will be provided training on: Prompt and appropriate intervention for resident behaviors De escalation and redirection of residents exhibiting unsafe or inappropriate behaviors Recognizing and reporting incidents including resident to resident encounters Timely notifications to Administration, Director of Nursing, physician, Geri psych nurse practioner [sic], OSDH [Oklahoma State Department of Health], local law enforcement, if appropriate, responsible party, other third party providers Complete and detailed documentation of incident and interventions immediately following incident as well as follow up interventions and resident actions, reactions or behaviors. Date of Compliance: 5/9/25 11:59 pm Care Plan Administrator, Director of Nursing, MDS Nurse, ADON will be in serviced on 5/9/25 on timely updates of resident care plan after incident and implementation of appropriate interventions. Care plans will be reviewed by DON/ADON to ensure interventions are in place and if current interventions are not successful new interventions are put in place. New or existing residents exhibiting behaviors that could be harmful to themselves or other residents will be identified timely, assessments and interventions will be implemented in accordance with physician and geri psych recommendations. Complete documentation will be done and reviewed by DON/ADMIN/Designee to ensure compliance. Date of Compliance: 5/10/25 12:00 noon On 05/12/25, after interviewing facility staff, reviewing documentation of in-service trainings, communication between the facility and the hospital and care plan audits, the IJ was lifted effective 05/12/25 at 12:24 p.m. The deficient practice remained at a pattern level with the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure residents were free from resident-to-resident abuse for 8 (#1, 3, 4, 5 ,6, 7, 8, and 9) of 9 sampled residents reviewed for abuse. The DON reported the facility census was 49. Findings: An undated facility policy titled Resident-to-Resident Altercations, read in part, Facility staff will monitor residents for aggressive/inappropriate behavior toward other resident, family members, visitors or to staff .If two residents are involved in an altercation, staff will: .Make any necessary changes in the care plan approaches any or all of the involved individuals; .If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. An admission record, dated 12/29/22, showed Res #2 had diagnoses which included schizophrenia, anxiety disorder, depression, restlessness and agitation. A care plan, initiated 01/11/23, showed Res #2 had hit other residents on 01/03/25 and 04/10/25. No new interventions had been implemented since 01/11/23. An ODH form 283, dated 01/03/25, showed Res #9 yelled at Res #2 and Res #2 hit Res #9 in the side of the head. The form also showed they were separated and assessed for injuries and staff would monitor and intervene if behaviors were noted. An ODH form 283, dated 01/08/25, showed Res #2 was observed with one hand on the back of Res #4's head and was about to hit Res #4 again when a CNA intervened. Res #4 had a small amount of blood on their nose. The form showed neuro checks were initiated. An ODH form 283, dated 02/08/25, showed Res #2 hit Res #3 in the back and side of their head in the hallway. The form also showed the residents were separated and assessed for injuries and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/07/25, showed Res #5 wandered into Res #2's room and Res #2 grabbed Res #5. The form also showed the residents were assessed for injuries and separated, and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/13/25, showed Res #2 hit Res #6. The form showed the residents were separated and assessed for injuries and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/16/25, showed Res #2 approached Res #3 in the hallway and hit them in the nose. The form showed the residents were separated and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/28/25, showed Res #2 walked up to Res #7, who was seated in a wheelchair and hit Res #7 in the back of the head. The form showed the residents were separated and assessed for injuries and staff were to intervene if further behaviors were noted. An ODH form 283, dated 04/10/25, showed Res #2 entered Res #8's room Res #8 stated Res #2 hit them. The form showed the residents were separated and assessed for injuries. A quarterly assessment, dated 4/10/25, showed Res #2 had a BIMS summary score of 9, which was indicative of moderate impairment in cognition for daily decision making. An ODH form 283, dated 05/01/25, showed Res #2 wandered into Res #1's room, a CNA entered the room and observed Res #2 hit Res #1 in the head. The form showed the residents were separated and assessed for injury. A Written Notice of Transfer/Discharge, dated 05/02/25, showed Res #2 was transferred to an inpatient psychiatric hospital on [DATE]. On 05/08/25 at 1:40 p.m., Res #3 stated in March Res #2 hit them in the face for no reason. On 05/08/25 at 2:20 p.m., CNA #1 stated Res #2 was confused and required frequent redirection. They also stated they were not aware of any special monitoring for Res #2. On 05/08/25 at 2:30 p.m., CNA #2 stated they tried to keep an eye on Res #2, but they were not on any type of additional monitoring. On 05/08/25 at 2:35 p.m., licensed practical nurse # 1 stated they tried to keep Res #2 busy as much as possible, but they were not on any special monitoring or precautions. They also stated the facility was planning on taking Res #2 back when they were discharged from the hospital. On 05/08/25 at 2:45 p.m., the DON stated they had tried to find Res #2 placement at another facility, but they are unable to locate a facility that would accept the resident, The DON stated the resident was out of the facility at the hospital right now, but they had agreed to take the resident back. They also stated they had not updated Res #2's care plan and the interventions in the care plan have not been effective.

Based on record review and interview, the facility failed to revise a resident's care plan for 1 (#2) of 9 sampled residents whose care plans were reviewed. The DON identified 49 residents resided in the facility. Findings: An undated facility policy titled Care Plans, Comprehensive Person-Centered, read in part, Assessments of residents are ongoing, and care plans are revised as information about the resident and the residents' conditions change. An admission record, dated 12/29/22, showed Res #2 had diagnoses which included schizophrenia, anxiety disorder, depression, restlessness and agitation. A care plan, initiated 01/11/23, showed Res #2 had hit other residents on 01/03/25 and 04/10/25. No interventions have been added to this care plan since 01/11/23. An ODH form 283, dated 01/03/25, showed Res #9 yelled at Res #2 and Res #2 hit Res #9 in the side of the head. The form also showed the residents were separated and assessed for injuries and staff would monitor and intervene if behaviors were noted. An ODH form 283, dated 01/08/25, showed Res #2 was observed with one hand on the back of Res #4's head and was about to hit Res #4 again when a CNA intervened. Res #4 had a small amount of blood on their nose. The form showed neuro checks were initiated. An ODH form 283, dated 02/08/25, showed Res #2 hit Res #3 in the back and side of their head in the hallway. The form also showed the residents were separated and assessed for injuries and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/07/25, showed Res #5 wandered into Res #2's room and Res #2 grabbed Res #5. The form also showed the residents were assessed for injuries and separated and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/13/25, showed Res #2 hit Res #6. The form showed the residents were separated and assessed for injuries and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/16/25, showed Res #2 approached Res #3 in the hallway and hit them in the nose. The form showed the residents were separated and staff were to monitor and intervene if further behaviors were noted. An ODH form 283, dated 03/28/25, showed Res #2 walked up to Res #7, who was seated in a wheelchair and hit Res #7 in the back of the head. The form showed the residents were separated and assessed for injuries and staff were to intervene if further behaviors were noted. An ODH form 283, dated 04/10/25, showed Res #2 entered Res #8's room and Res #8 stated Res #2 hit them. The form showed the residents were separated and assessed for injuries. A quarterly assessment, dated 4/10/25, showed Res #2 had a BIMS summary score of 9, which was indicative of moderate impairment in cognition for daily decision making. An ODH form 283, dated 05/01/25, showed Res #2 wandered into Res #1's room, a CNA entered the room and observed Res #2 hit Res #1 in the head. The form showed the residents were separated and assessed for injury. On 05/08/25 at 2:45 p.m., the DON stated they had not updated Res #2's care plan and the interventions in the care plan had not been effective.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for one (#1) of five sampled residents reviewed for abuse and neglect. The DON reported the census was 51. Findings: An Abuse and Neglect policy, dated 03/01/14, read in part, The facility will thoroughly investigate any and all allegations of abuse .The facility administrator will be designated as the abuse coordinator and will conduct and/or facilitate interviews of the direct resident(s) involved in the allegation, any interviewable residents, any staff associated with the allegation, and any visitors that have knowledge of or witnessed the allegation .A written report or statement will be gathered and maintained on all interviews. Resident #1 had diagnoses which included schizophrenia and anxiety disorder. A quarterly assessment, dated 10/10/24, documented Resident #1 was severely impaired for daily decision making. An OSDH Incident Report Form, dated 12/15/24, documented an allegation of abuse involving Resident #1 and an LPN in the resident's room. The investigation consisted of a statement from the alleged abuser and a statement from the reporter of the alleged abuse. No interviews from residents, other staff members, or visitors were located. On 12/19/24 at 1:39 p.m., LPN #2 stated all allegations of abuse should be thoroughly investigated. On 12/19/24 at 2:16 p.m., the DON stated other residents were not interviewed because most of them were not cognitively intact. They also stated other staff members were not asked to provide statements because they were not in the area. They further stated that a more comprehensive investigation should have been completed.

Based on observation, record review, and interview, the facility failed to ensure: a. foods were covered and dated in the refrigerator for one of three refrigerators observed in the kitchen; b. infection control was maintained during meal service for one (the noon meal) of one meal observed during meal service; c. infection control was maintained when meals were delivered to residents who ate in their rooms for one of two meals observed during dining; and d. the ice machine was maintained in a sanitary manner for one of one ice machines observed. The DON identified 47 residents who received nourishment from the kitchen. Findings: The undated Food Storage policy, read in parts, .Refrigeration .All foods should be covered, labeled, and dated . The undated, Cleaning Instructions Cleaning Ice Machine and Scoop policy, read in part, .The ice machine and equipment [scoops] will be cleaned on a regular basis to maintain a clean, sanitary condition . The Assisting the Resident with In-Room Meals policy, dated December 2013, read in part, .Employees must wash their hands before serving food to residents. It is not necessary to wash hands between each resident tray; however, if there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash his/her hands before serving food to the next resident . The Preventing Foodborne Illness - Food Handling policy, dated July 2014, read in part, .Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing . 1. On 09/30/24 at 9:23 a.m., eleven dessert dishes with sliced peaches were observed uncovered and not dated, on a tray, in the refrigerator. The dietary manager stated the dietary staff had prepared the peaches earlier, but had not covered or dated them. The dietary manager stated foods stored in the refrigerator were to be covered and dated. 2. On 10/01/24 at 11:52 a.m., cook #1 was observed to don gloves and touch plates, the counter top, plate covers, ladle handles, trays, meal tickets, and bagged sandwiches. [NAME] #1 was observed to obtain chips from a bag with the same gloved hands and place them on plates. [NAME] #1 was observed to obtain small bowls of dessert over the top of the bowl with the same gloved hands. On 10/01/24 at 12:13 p.m., cook #2 was observed to touch meal tickets, the counter top, ladle handles, plates, trays, plate covers and then obtain chips from a bag and plate them with their bare hands. [NAME] #2 was observed to don gloves and touch meal tickets, the counter top, ladle handles, plates, trays, plate covers and then obtain chips from a bag and plate them with the same gloved hands. [NAME] #2 was then observed to obtain a slice of turkey from the steam table and place on a plate with the same gloved hands. [NAME] #2 was observed to obtain small bowls of dessert with their thumb inside the bowl with the same gloved hands. On 10/01/24 at 1:19 p.m., cook #1 stated they were supposed to wash their hands and utilize gloves if they had to touch food. [NAME] #1 stated they should have changed their gloves before obtaining chips from the bag. [NAME] #1 stated they were supposed to transport dessert cups to meal trays by the sides, not over the top of the bowl. On 10/01/24 at 1:23 p.m., cook #2 stated they should have poured the chips from the bag. [NAME] #2 stated they were to plate bowls of dessert by picked them up on the sides. On 10/01/24 at 1:25 p.m., the dietary manager stated if staff touched food they were to don gloves to maintain infection control. They stated bowls of dessert should be transported by the sides of the bowls, not over the top or with fingers in the bowls. On 10/02/24 at 11:59 a.m., the dietary manager stated they had thought about plating chips and the staff should have utilized tongs or another utensil to plate them. 3. On 09/30/24 at 12:16 p.m., CNA #3 was observed to deliver meal trays to residents who ate in their rooms. CNA #3 was observed to enter room [ROOM NUMBER], obtained a soda pop from the resident's personal refrigerator, and poured it into their cup. CNA #3 was not observed to sanitize their hands. On 09/30/24 at 12:20 p.m., CNA #3 was observed to enter room [ROOM NUMBER], moved personal items from the bedside table, uncovered the resident, assisted the resident to sit up in bed, and moved the bedside table over the resident. CNA #3 was not observed to sanitize their hands. On 09/30/24 at 12:28 p.m., CNA #3 was observed to enter the code to the memory care unit and without sanitizing their hands delivered a meal tray to room [ROOM NUMBER]. CNA #3 was observed to move the bedside table and provide meal set up. CNA #3 was not observed to sanitize their hands. On 10/03/24 at 10:30 a.m., CNA #3 stated they were to sanitize their hands if they handled personal items during meal delivery. They stated they had not sanitized their hands on 09/30/24 and did not know why they forgot to sanitize after touching personal items and assisting a resident with positioning. On 10/03/24 at 10:55 a.m., the DON stated staff were to sanitize their hands between each resident when delivering meal trays. 4. The Bi-Monthly Ice Machine Cleaning Log, dated 2024, documented the ice machine had last been cleaned on 09/09/24. On 09/30/24 at 9:30 a.m., the ice machine was observed with the dietary manager. A slimy pink substance was observed on the lower deflector panel in the bin. The dietary manager stated they did not know what the substance was. They stated the ice machine was cleaned monthly. Around and on the deflector panel in the upper portion of the ice machine, brown, black, and yellow substances were observed. On 10/02/24 at 7:14 a.m., the maintenance supervisor stated they cleaned the ice machine with a chemical solution once a month and twice a month it was checked and wiped down.

Based on observation, record review, and interview, the facility failed to ensure holding temperatures were obtained for one (noon meal) of one meal observed for meal service. The DON identified 47 residents who received nourishment from the kitchen. Findings: The undated Food Temperatures policy, read in part, .The temperatures of the food items will be taken and properly recorded for each meal . On 10/01/24 at 11:20 a.m., the noon meal service was observed. The Daily Food Temperature Log, dated 10/01/24 at 11:30 a.m., documented the noon meal food temperatures had been obtained. On 10/01/24 at 11:49 a.m., cook #1 was observed to plate the noon meal. Holding temperatures were not observed to be obtained by dietary staff from 11:20 a.m. through 11:49 a.m. [NAME] #1 stated they had obtained the temperature of the foods when they removed the food from the oven. [NAME] #1 stated they did not obtain holding temperatures before serving foods. On 10/01/24 at 12:11 p.m., the dietary manager stated food temperatures were to be obtained before they served every meal and they were to document the food temperatures on the log. The dietary manager asked cook #1 when they had obtained the documented temperatures on the log. [NAME] #1 stated they obtained the temperatures when they removed the food from the oven. On 10/01/24 at 12:17 p.m., cook #1 stated they had removed the food from the oven at approximately 10:40 a.m. [NAME] #1 stated they could tell the food was still hot because of the steam from the steam table. On 10/01/24 at 1:25 p.m., the dietary manager stated they did not know the why cook #1 had not obtained holding temperatures for the noon meal or why they had documented they obtained them at 11:30 a.m. The dietary manager stated, You were in the kitchen at that time.

Based on observation and interview, the facility failed to ensure pureed foods were a smooth consistency for one (noon meal) of one meal observed for pureed foods. The DON identified two residents who received pureed diets. Findings: On 10/01/24 at 11:20 a.m., cook #1 was observed to puree the noon meal which consisted of turkey with gravy, dressing, mixed vegetables, bread, and lemon pudding. On 10/01/24 at 11:22 a.m., cook #1 was observed to place turkey and gravy into a food processor. The turkey and gravy was observed to contain visible pieces of food. The turkey with gravy was not observed to be a smooth consistency. [NAME] #1 stated, This is how I will serve it. On 10/01/24 at 11:28 a.m., cook #1 was observed to place dressing with gravy into a food processor. The dressing was observed to contain visible pieces of food, some the size of a pencil eraser. The dressing was not observed to be a smooth consistency. [NAME] #1 placed the dressing onto the steam table. On 10/01/24 at 11:32 a.m., cook #1 was observed to place mixed vegetables (which consisted of green beans, carrots, green peas, and corn) with their juices, into the food processor. The mixed vegetables were observed to be of a thin, runny consistency with pieces of the vegetables remaining. [NAME] #1 placed the mixed vegetables on the steam table. On 10/01/24 at 11:50 a.m., cook #1 plated the noon meal for the two residents on a pureed diet and dietary aide #2 placed the trays on the meal cart. On 10/01/24 at 12:02 p.m., cook #1 stated the meal cart was ready to be delivered to the dining room for service. Dietary aide #2 began taking the cart to the dining room. [NAME] #1 was asked to remove the two trays that contained the pureed diets. [NAME] #1 stated they processed foods for residents on pureed diets until the food resembled something like baby food. They stated they ensured pureed meals were smooth by visually observing the food items after processing for any remaining food pieces. On 10/01/24 at 12:04 p.m., the dietary manager stated pureed foods were to be the consistency of smooth mashed potatoes. The dietary manager observed the two meals of pureed food and stated the turkey, dressing, and mixed vegetables were a little clumpy and the mixed vegetables were too thin. They stated they ensured pureed foods were served at a smooth consistency by having the cooks sample the foods after processing.

Based on record review and interview, the facility failed to ensure baseline care plans were completed for one (#150) and failed to ensure residents and/or resident representatives were provided a summary of the baseline care plan for one (#29) of 14 sampled residents whose care plans were reviewed. The DON identified 47 residents who resided in the facility. Findings: The Care Plans-Baseline policy, dated December 2016, read in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .The resident and their representative will be provided a summary of the baseline care plan . 1. Resident #150 had diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, and pressure ulcer. On 09/30/24 at 11:23 a.m., Resident #150 stated they had recently admitted to the facility. Resident #150 stated they had not had a care plan meeting or received a summary of their baseline/initial plan of care. Review of the clinical record did not reveal a baseline care plan had been completed. On 10/03/24 at 8:28 a.m., the DON stated the baseline care plan for Resident #150 should have been completed within 48 hours of admission to the facility. The DON stated they had reviewed the clinical record and did not know why a baseline care plan had not been completed. 2. Resident #29 had diagnoses which included diabetes, anxiety, and chronic pain. The baseline care plan, dated 08/03/24, was left blank on the resident/resident representative signature spaces. On 10/02/24 at 11:11 a.m., the DON stated they were not sure who was to receive a summary of the baseline care plan. They stated they contacted resident representatives 10-14 days after admission for a care plan meeting. On 10/03/24 at 8:47 a.m., the DON stated they had reviewed the clinical record, but had not found documentation a summary of the baseline care plan had been provided to the resident or the resident representative. On 10/03/24 at 9:36 a.m., Resident #29 stated staff had not discussed their baseline care plan with them upon admission.

Based on observation and interview, the facility failed to ensure survey results were posted and accessible for residents and visitors. The DON identified 47 residents who resided in the facility. Findings: An undated Survey Results policy, read in parts, .survey results are in the front lobby of the facility. The location of the facility survey results is identified with a sign posted on the cabinet. Any resident and or visitor will have access to the results if desired . On 10/01/24 at 2:57 p.m., four residents in the resident council meeting stated they did not know where survey results were located. On 10/01/24 at 3:15 p.m., survey results, or signage on where survey results were located, was not observed in the facility. On 10/01/24 at 3:17 p.m., the activities director stated they did not know where survey results were located. On 10/01/24 at 3:18 p.m., the administrator stated the survey results were located in the lobby, which was a locked area, away from resident rooms and common areas. On 10/01/24 at 3:20 p.m., the administrator stated some survey results were in the DONs office for review, but they normally kept them in the front lobby. They stated if a resident from the locked units wanted access to the survey results they would need to knock on the door to the front lobby and staff would assist them. On 10/01/24 at 3:23 p.m., the DON stated the binders with the survey results had been on the book shelf in their office for approximately four months. They stated they were not aware the survey results were to be made accessible to residents and visitors. On 10/01/24 at 3:43 p.m., the administrator stated residents and visitors were made aware of the location of the survey results with posted signage, but the sign had been removed.

Based on observation, record review, and interview, the facility failed to ensure infection control protocols for enhanced barrier precautions were maintained during medication administration and wound care. The DON identified nine residents who were on enhanced barrier precautions. Findings: On 10/01/24 at 12:02 p.m., LPN #2 and LPN #3 were observed during medication administration for insulin and blood sugar monitoring. LPN #2 donned PPE for room [ROOM NUMBER], Resident A, who was on EBP. LPN #2 was given the supplies to check the blood sugar for Resident B. After LPN #2 obtained the blood sugar results, they handed the used supplies to LPN #3 who discarded them, donned new gloves, and provided LPN #2 with the supplies needed for checking the blood sugar for Resident A. LPN #2 did not remove their gloves, or sanitize their hands prior to checking the blood sugar of Resident A. The used supplies were then handed back to LPN #3. LPN #3 then provided supplies and drew up the insulin for LPN #2, who observed the insulin being drawn into the syringe. The amount was verified as correct. LPN #2 then administered the insulin to Resident A without changing their gloves or sanitizing their hands. On 10/02/24 at 7:15 a.m., CMA #1 was observed during medication administration for room [ROOM NUMBER] B. CMA #1 came out of a resident room, approached the medication cart, did not sanitize their hands, then began to prepare medications to administer for room [ROOM NUMBER] B. CMA #1 did not sanitize their hands prior to administering the medications. On 10/03/24 at 9:25 a.m., CMA #1 stated they were to sanitize/wash their hands between residents when administering medications. On 10/03/24 at 9:28 a.m., the DON and infection preventionist stated staff were expected to wash hands or sanitize their hands anytime a resident was touched and between residents. The infection preventionist stated LPN #2 should have washed/sanitized their hands. The DON stated the nurse who drew the insulin should have given the insulin. The DON stated the expectation was for staff to follow protocol and policy when providing wound care regarding infection control.

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for one (#36) of five sampled residents who were reviewed for unnecessary medications. The DON identified 47 residents who resided in the facility. Findings: Resident #36 had diagnoses which included dementia, mood disorder, and unspecified psychosis. The Physician's Order, dated 04/23/24, documented to obtain a lipid panel and PSA for annual labs. The Progress Note, dated 04/26/24, documented the resident had refused lab for three days. Review of the clinical record revealed the resident had complied with obtaining labs twice in June 2024 and three times in July 2024. The labs obtained did not include a PSA for annual labs per the physician's order. On 10/01/24 at 9:35 a.m., the ADON stated the lipid panel was completed in June 2024, but they would need to look for the lab results for the PSA. The ADON stated the resident would initially refuse labs, but after they talked to the resident and explained the lab to them they were compliant and agreeable to obtaining labs ordered by the physician. On 10/01/24 at 10:02 a.m., the DON stated when the resident complied with obtaining labs in June and July 2024 they had not obtained the PSA because it was no longer in the electronic clinical record. The DON stated they did not find documentation staff had spoken to the resident and explained the lab to the resident in April 2024. The DON stated they had not been monitoring to ensure labs, ordered by the physician, had been obtained or follow up had been done if the resident had a history of initially refusing labs until they were explained to them.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served at palatable temperatures for one (#29) of one sampled resident who was reviewed for food. The DON identified 47 residents who received nourishment from the kitchen. Findings: The undated Food Temperatures policy, read in part, .Temperatures should be taken periodically to ensure hot foods stay above 140 [degrees] F and cold foods stay below 40 [degrees] F during the portioning, transporting and serving process until received by the resident . On 09/30/24 at 10:35 a.m., Resident #29 stated hot foods were served cold all the time. The resident stated they ate their meals in their room. On 10/02/24 at 11:51 a.m., the hall trays were observed to be prepared and ready for service on a metal cart with a plastic zippered cover. A test tray was placed on the hall cart. The noon meal consisted of penne pasta with chicken and alfredo sauce, green beans, bread, and spiced apples. On 10/02/24 at 12:04 p.m., CNA #2 was observed to obtain the hall cart from the dining room and begin delivering meal trays. On 10/02/24 at 12:15 p.m., CNA #2 had delivered the last meal tray on the hall cart to Resident #29 and the test tray was obtained. The penne pasta with chicken and alfredo and the green beans were observed to be slightly warm when tasted. On 10/02/24 at 12:31 p.m., the dietary manager stated they were to obtain food holding temperatures before serving, utilize insulated lids, and use insulated food carts to ensure foods were served at a palatable temperature. On 10/03/24 at 8:50 a.m., the DON stated they could not say if hot foods were served hot to residents who ate meals in their rooms.

Based on record review and interview, the facility failed to ensure supplements were offered/documented for one (#29) of one sampled residents who was reviewed for nutrition. The dietary manager identified 14 residents who was ordered supplements in the facility. Findings: Resident #29 had diagnoses which included moderate protein calorie malnutrition. The Dietician's Recommendation for Primary Care Providers form, dated 08/17/24, documented the resident was 26% below ideal body weight, had a diagnosis of protein calorie malnutrition, and recommended a supplement twice daily between meals. The physician agreed with the dietician recommendation. The electronic clinical record, dated 08/02/24, documented the resident's weight was 145 pounds. A Physician's Order, dated 08/20/24, documented the resident was ordered a dietary supplement between meals. A Physician's Order, dated 08/23/24, documented the resident was ordered Ensure three times per day. The electronic clinical record, dated 09/05/24, documented the resident's weight was 135.2 pounds, which indicated a 6.76 % weight loss in one month. Review of the Task-Nutrition, dated 09/02/24 through 10/01/24, revealed supplements were documented as provided/offered 36 times out of 72 opportunities. Some entries documented response not required. On 10/01/24 at 3:52 p.m., CMA #2 stated the dietary department provided supplements. On 10/01/24 at 3:54 p.m., Drink Aide #1 stated they provided supplements on the snack cart, but they did not document. On 10/01/24 at 3:57 p.m., the dietary manager stated the nursing department documented the amount of the supplements consumed. On 10/01/24 at 4:01 p.m., the DON stated the dietary department provided the supplements on the snack cart and the CNAs documented the amount consumed or refusals in the nutrition task. On 10/02/24 at 11:05 a.m., the DON stated response not required was documented on the task if the resident ate 76-100% of their meal. They stated the resident was offered a supplement between meals at snack time and if they ate less than 76%. On 10/02/24 at 12:28 p.m., Resident #29 stated they were offered snacks and shakes two to three times per day. The resident stated they refused snacks and supplements at times. On 10/03/24 at 8:41 a.m., the DON stated they changed the documentation requirements in tasks to document the supplements offered/provided for meal replacement and those offered/provided between meals, to monitor nutritional intake, for residents with significant weight loss who were ordered supplements as a nutritional intervention.

Based on observation, record review and interview, the facility failed to ensure interventions were in place to prevent reduction in range of motion/mobility for one (#29) of one sampled residents who were reviewed for range of motion/mobility. The DON identified seven residents who had limited range of motion. Findings: Resident #29 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction. The admission assessment, dated 08/02/24, documented no impairments to the upper or lower body. A Progress Note, dated 08/03/24 at 2:00 a.m., documented Resident #29 admitted to the facility on [DATE] with noted left hand weakness and without grasp due to a cerebral vascular accident. On 10/02/24 at 8:30 a.m., CNA #1 stated Resident #29 did not allow them to do anything with their hand. They stated they had not seen anything in their room for the left hand. On 10/02/24 at 8:35 a.m., LPN #1 stated Resident #29 was new to them. They stated the resident had no limitation in range of motion and had no interventions for any impairments. On 10/03/24 at 11:36 a.m., the DON stated Resident #29 had a functional dominate right hand, the left hand was not completely functional, but was not contracted. They stated the impairment should be on the assessment and the care plan. On 10/03/24 at 12:17 p.m., the DON stated the impairment should have been added and was not captured. They stated they did not do the assessment so they could not say why it was not done.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#29) of 23 sampled residents who were reviewed for comprehensive care plans. The administrator identified 47 residents who resided at the facility. Findings: Resident #29 had diagnoses which included cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis. A Care Plan, initiated 08/02/24, documented focus for DNR status and indwelling catheter. No other concerns were documented on the comprehensive care plan. An admission assessment for Resident #29, dated 08/15/24, documented ten areas of concern for care planning as follows: cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, dehydration fluid maintenance, dental care, pressure ulcer, and psychotropic drug use. Only one of the concerns were included in the comprehensive care plan. On 10/03/24 at 8:47 a.m., the DON stated a comprehensive care plan should have been developed and did not know the reason it was not. They stated they had not been monitoring, but would start. 41809

Based on observation, record review, and interview, the facility failed to ensure resident mobility was included in the resident assessment and the plan of care for one (#29) of one sampled residents who was reviewed for mobility and positioning. The DON identified seven residents with limited range of motion. Findings: Resident #29 had diagnoses which included cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis. An admission assessment, dated 08/02/24, did not document the impairment to the left upper extremity. Review of the clinical record revealed the comprehensive care plan had not been developed. On 08/03/24 at 2:00 a.m., a Health Status Note, documented Resident #29 admitted to the facility with a noted weak left hand and did not have a grasp due to a CVA. A Functional Abilities and Goals Assessment, dated 08/03/24, documented Resident #29 had no impairment to the upper or lower body. A Functional Abilities and Goals Assessment, dated 09/23/24, documented Resident #29 had impairment to the upper and lower left side. On 09/30/24 at 10:32 a.m., the left hand of Resident #29 appeared to be contracted. The resident was able to open their left hand slightly, but no devices were in place and Resident #29 denied any restorative therapy. On 10/02/24 at 8:30 a.m., CNA #1 stated Resident #29 did not allow staff to do anything with the left hand. They stated they had not seen anything in the room for the left hand. CNA #1 stated the resident would pull their left hand away in the shower when asked to wash it. On 10/02/24 at 8:35 a.m., LPN #1 stated Resident #29 was new to them. They stated Resident #29 did not have any limitation in range of motion and did not have interventions for contractures. On 10/03/24 at 11:36 a.m., the DON stated the dominate hand of Resident #29 was functional, the left hand was not completely functional, but was not contracted. They stated it should be on the assessment and in the care plan. On 10/03/24 at 12:17 p.m., the DON stated the impairment to the left hand should have been added and was not captured. They stated they did not do the assessment and could not say the reason it was not done.

Based on observation, record review and interview, the facility failed to ensure the care plan was revised and updated for one (#14) of 12 sampled residents whose care plans were reviewed. The administrator identified 47 residents who resided at the facility. Findings: Resident #14 had diagnoses which included pressure ulcer of left heel and diabetes type II. The care plan for Resident #14 documented a wound to the left heel was initiated 02/21/24 and resolved 04/24/24. The care plan did not document any further updates for pressure ulcers or deep tissue injuries. A Physician's Order, dated 09/06/24, documented to cleanse the wound with wound cleanser, pat dry then apply Santyl External Ointment 250 UNIT/GM (Collagenase) to the right heel topically one time a day for wound care, and cover with silicone border dressing daily until resolved. A quarterly assessment, dated 09/24/24, documented Resident #14 had no deep tissue injuries or pressure wounds. On 10/02/24 at 9:53 a.m., wound care was observed for Resident #14. The left heel wound was observed to be a closed wound, dark in color, and approximately the size of the tip of a finger. On 10/02/24 at 3:10 p.m., the DON stated the MDS coordinator was responsible to ensure the care plan was revised/updated. They stated the wound should have pulled over from the quarterly assessment. They reviewed the quarterly assessment and care plan and stated the care plan should have been updated.

Based on observation and interview, the facility failed to ensure the physical environment of the facility was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility. Findings: On 07/24/23 at 10:36 a.m., upon entrance to the facility the wood laminate floor was observed to be missing and buckled. On 07/25/23 at 9:11 a.m., a tour of the front shower room was conducted. The following observations were made: a. the base board was missing on the wall adjacent to the hand sink. There was an accumulation of black residue on the wall, b. material was peeling off of the hand sink cabinet and the cabinet was warped, and c. there was an accumulation of black residue on the floor around the hand sink cabinet. On 07/25/23 at 9:16 a.m., a tour of the shower room on the back hall was conducted. The following observations were made: a. material was peeling off of the floor, b. base board tiles were missing, and c. there was a hole in the wall around the shower head and the tile was missing. On 07/25/23 at 9:25 a.m., CNA #1 was asked how staff ensured the shower rooms were clean and maintained. They stated the aides disinfected the shower chairs before and after each use. They they stated housekeeping cleaned the shower rooms daily. They stated maintenance concerns were reported to the maintenance department for repairs. On 07/25/23 at 9:35 a.m., the housekeeping supervisor was asked how staff ensured the shower rooms were kept clean and maintained in good repair. They stated staff cleaned daily and reported maintenance concerns to the maintenance supervisor. On 07/25/23 at 3:50 p.m., a tour of the hallways and common areas were conducted. The following observations were made: a. the end cap was missing off the the handrail near the entrance to the solarium door and metal was exposed, b. floor tiles were cracked and/or missing in the solarium, c. plastic was missing off of the handrail between room [ROOM NUMBER] and the linen closet and the metal was exposed, d. the end cap was missing off of the handrail next to the laundry room and the metal was exposed, e. the end cap was missing off of the handrail next to room [ROOM NUMBER] and metal was exposed, f. there was a gap between the end cap and the handrail between room [ROOM NUMBER] and the therapy office and metal was exposed, g. material was peeling of off the wall and the wall paper was buckled in the lift storage area on the back hall, h. there were floor tiles missing in the lift storage area on the back hall, i. the end cap was missing off of the handrail next to room [ROOM NUMBER] and metal was exposed, j. there was a gap between the end cap and the handrail next to room [ROOM NUMBER] and metal was exposed, k. wall paper was peeling off of the wall between room [ROOM NUMBER] and the furnace room, l. the end cap was missing off of the handrail next to room [ROOM NUMBER] and metal was exposed, and m. there was a gap and daylight was visible under the back door to the smoking area. On 07/25/23 at 4:06 p.m., a tour of the laundry room was conducted. The following observations were made: a. there was an accumulation of lint on the floor and the wall behind the domestic washer and dryer, b. there was a gap and daylight was visible under the back door, and c. floor tiles were missing. On 07/25/23 at 4:12 p.m., the laundry supervisor was asked how staff ensured the laundry room was kept clean and maintained in good repair. They stated they cleaned daily and maintenance concerns were reported to maintenance. They were made aware of the laundry observations. On 07/26/23 at 9:10 a.m., the administrator and BOM were asked how staff ensured the facility was kept clean and maintained in good repair. They stated staff cleaned the facility on a daily basis. They stated there was a maintenance log for staff to document repairs needed. They were made aware of the above observations.

Based on record review and interview, the facility failed to notify the physician of vital signs out of parameter per physician orders for two (#41 and #46) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/24/23, documented 51 residents resided in the facility. Findings: 1. Res #41 had diagnoses which included hypertension. A physician order, dated 06/29/23, documented to administer amlodipine 5 mg two times per day for hypertension. The order documented to hold the medication for systolic blood pressure less then 100 or diastolic blood pressure less than 60 and notify the primary care physician. A physician order, dated 06/29/23, documented to administer losartan 50 mg two times per day for hypertension. The order documented to hold the medication for systolic blood pressure less then 100 or diastolic blood pressure less than 60 and notify the primary care physician. The July 2023 MAR documented the amlodipine and losartan were held eight out of 50 opportunities for blood pressure parameters. A record review documented there were no progress notes to indicate the physician was notified for the held medications and/or low blood pressures. On 07/26/23 at 12:47 p.m., the DON stated there was no documentation the physician was notified for the held medications. They stated the nurse should have been notified the medications were held, so the physician could be contacted. 2. Res #46 had diagnoses which included diabetes mellitus. A physician order, dated 04/25/23, documented to administer Novolog (insulin aspart) solution per sliding scale before meals and at bedtime. The order documented for blood sugars from 401 to 600 to administer seven units and call the physician. The June 2023 MAR documented Res #46's blood sugar was above 401 for 10 of 120 opportunities. The July 2023 MAR documented Res #46's blood sugar was above 401 for five of 97 opportunities. On 07/25/23 at 11:01 a.m., LPN #2 was asked how physician notification for out of parameter vital signs, including blood sugar, were documented. They stated the documentation would be in a progress note. On 07/25/23 at 12:41 p.m., the DON stated the physician notification should be in a progress note. They stated they would review the chart for documentation of physician notification. On 07/26/23 at 7:43 a.m., the DON stated the insulin order was entered incorrectly so the staff were not triggered to document for out of parameter vital signs. They stated the physician was not contacted for the high blood sugars as far as they were aware.

Based on observation, record review, and interview, the facility failed to ensure code status orders were accurately documented for two (#23 and #51) of three residents sampled for advance directives. The Resident Census and Conditions of Residents form, dated [DATE], documented 51 residents resided in the facility. Findings: 1. Res #23 had diagnoses which included schizophrenia, bipolar disorder, and hypertension. A facility Advance Directive policy, dated [DATE], documented in part .Information about whether or not the resident has executed an advance directive shall be displayed prominent in the medical record .The director of nursing or designee will notify the attending physician of advance directives so that the appropriate orders can be documented in the resident's medical record and plan of care . A facility Do Not Resuscitate Order policy, dated [DATE], documented in part, .Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders sheet maintained in the resident's medical record .Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order . An Oklahoma Do-Not-Resuscitate (DNR) Consent Form, dated [DATE], documented the resident wished to be in DNR status. The resident's EHR did not document a code status. The care plan, last reviewed [DATE], documented the resident's code status as DNR. On [DATE] at 2:39 p.m., Res #23's name tag was observed on their door. The name was printed in red. LPN #1 stated the name tags were color coded according to code status. They stated the red names were for DNR residents and green signified the resident was a full code. On [DATE] at 8:09 a.m., the ADON stated Res #23 had revoked their DNR at the hospital for placement of a feeding tube in 2021 and was now a full code. They stated the resident should have an order to be full code. On [DATE] at 8:10 a.m., the social services director stated it was their responsibility to update the names on the door when a code status change occurred. They stated a red name meant the resident was a DNR. They were informed of the information provided by the ADON and stated they would get clarification. On [DATE] at 8:17 a.m., the ADON stated the facility was to follow the policy for code status. On [DATE] at 8:40 a.m., LPN #3 was asked if Res #23 was reported unresponsive, how would they determine code status. The LPN reviewed the resident's chart and at 8:45 a.m., stated the resident was a DNR. When asked what information was used to determine the code status, LPN #3 stated they saw the DNR form in the resident's EHR. The LPN stated CPR would not be initiated for Res #23 if they were reported unresponsive. The LPN stated they had not been informed to check the name tags or any other methods to determine code status for residents. A Resuscitation Designation Order form, received on [DATE] at 9:10 a.m., documented Res #23 wished CPR to be performed at the facility in the event of cardiac or respiratory arrest. On [DATE] at 9:30 a.m., the administrator provided documentation of Res #23's code status wishes. The administrator stated the revocation of DNR was effective as of the date of the document. 47751 2. Res #51 had diagnoses which included chronic obstructive pulmonary disease, heart failure, and hypertension. An admission assessment, dated [DATE], documented the resident was mildly cognitively impaired. Res #51's EHR was reviewed and did not document a code status for the resident. On [DATE] at 08:17 a.m., the DON was asked if Res #51 had a code status. The DON stated Res #51 was a DNR, but it was not documented in their EHR. On [DATE] at 8:31 a.m., the ADON was asked if Res #51 had a code status. They stated the resident did not have a documented code status. They stated there should have been a code status documented in the resident's chart.

On 09/15/22 at 11:45 a.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health (OSDH) related to a resident, who had a court ordered return from an inpatient psychiatric hospital signed by an administrative law judge, experienced a facility-initiated discharge into the care of a homeless family member with a known recent psychiatric hospitalization and to which the facility continually documented was not able to care for the resident's needs. The clinical record documented the facility-initiated discharge was requested by the resident and their family member and occurred less than 24 hours after the resident's return to the facility. At 1:15 p.m., the administrator was notified of the IJ situation and was asked to provide a plan of removal. On 09/16/22 at 7:34 p.m., the administrator provided an acceptable plan of removal. The facility's plan of removal documented: Plan of Removal Step #1 The facility will continue to contacting [Resident #1] by phone weekly to ensure [pronoun omitted] is safe and being cared for until the resident has secure home health services and appropriate living arrangements. If the facility determines that [Resident #1] is not safe or being cared for, they will immediately notify the proper authorities in Missouri. All calls will be documented in the resident's discharged chart in PCC. Step #2 The Social Services Director faxed referrals for Home Health Services to Amedisys in Oklahoma, Cox Health and Integrity Home Health both in [NAME], Missouri. A message was left for [Resident #1] that we faxed three home health referrals for services. Social Services will follow-up Monday with the 3 Home Health Services that were faxed along with [Resident #1]. Social Services will follow-up with the results of the phone calls with the Administrator by 10:00 am Monday to determine further steps that might be needed. Step #3 All charge nurses, Director of Nursing, Assistant Director of Nursing, Administrator and Social Services staff will be in-serviced on the Proper Process to follow to ensure all resident and or resident representative-initiated discharges are handled per the Federal & State Regulations. Step #4 The Administrator or Director of Nursing will review all pending or anticipated discharges to ensure that the interdisciplinary team have reviewed the comprehensive care plan and develop a discharge plan per the Federal & State Regulations. Specifically, as outlined in 483.21 Step #5 All anticipated discharges will be discussed during weekday clinical meetings and the interdisciplinary team will review the discharge plan to determine if the residents discharge needs have been properly identified and addressed. Step #6 The discharge plan will be reviewed by the Medical Director and Clinical Director prior to discharge to ensure the discharge plan adequately meets the residents needs per 483.21. The IJ was removed on 09/19/22 at 2:26 p.m., after all components of the plan of removal had been completed. The deficient practice remained at an isolated level of harm. Based on interview and record review, the facility failed follow the regulatory requirements for facility initiated transfers and discharges for a resident who experienced a facility-initiated transfer to an inpatient psychiatric hospital; received an involuntary discharge notice while inpatient and denied transfer back to the facility; was granted a return transfer based on the order of an administrative law judge; and incurred a facility-initiated discharge to the community within 24 hours of returning to the facility without sufficient preparation and orientation for one (#1) of three residents sampled for discharges. Resident #1 was discharged into the care of a homeless family member/POA with a known recent inpatient hospitalization in an acute psychiatric center and to which the facility documented was not able to meet the resident's needs as POA. The facility provided the location, transportation, and the monetary means for the resident and POA to pay for an extended stay in an out of state motel room, negating the resident's Oklahoma Medicaid coverage. The facility failed to assist in setting up community resources such as applying for Medicaid coverage in Missouri, home health, or a primary care physician to aide in the care of resident #1, resulting in the resident utilizing emergency services three times (09/12/22, 09/18/22, and 09/20/22) within the first few weeks of residing in the community. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census and condition identified 51 residents. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 12/24/21, documented the resident entered the facility from a psychiatric hospital, was cognitively intact and was feeling down, depressed, or hopeless. The assessment documented the resident exhibited verbal behavioral symptoms directed toward others. The assessment documented the resident required limited to extensive assistance with activities of daily living. A notarized letter from the attending physician, dated 01/14/22, read in part, .In my medical opinion, [resident #1] is, to a reasonable degree of medical certainty, mentally and physically incapacitated, resulting in [pronoun omitted] inability to manage [pronoun omitted] medical, personal, and financial affairs effectively .[Resident #1] currently resides at Betty Ann Nursing Center and requires medical management and 24-hour supervision for [pronoun omitted] complex medical conditions, assistance with all [pronoun omitted] instrumental ADLS, and basic ADLS. [Resident #1] conditions are permanent and progressive . A notarized letter from physician #2, dated 01/14/22, read in part, .After review of [resident 1] clinical chart it's in my medical opinion, [resident #1] is, to a reasonable degree of medical certainty, mentally and physically incapacitated, resulting in [pronoun omitted] inability to manage [pronoun omitted] medical, personal, and financial affairs effectively .[Resident #1] currently resides at Betty Ann Nursing Center and requires medical management and 24-hour supervision for [pronoun omitted] complex medical conditions, assistance with all [pronoun omitted] instrumental ADLS, and basic ADLS. [Resident #1] conditions are permanent and progressive . An abuse and neglect hotline submission, dated 03/22/22, documented the resident was sexually inappropriate toward staff, refused care, and was verbally and physically aggressive toward other residents. The submission read in part, .This resident frequently calls [POA] that lives out of state and the facility has been notified by another family member that this is very concerned [sic] that's resident's [POA] is not capable of care for this resident's needs . The quarterly assessment, dated 06/26/22, documented the resident was cognitively intact, had fluctuating changes in mental status (inattention, disorganized thinking, altered level of consciousness), had physical and verbal behavioral symptoms directed toward others, and rejected care. The assessment documented the resident required supervision to limited assistance with most activities of daily living. A progress note, dated 07/14/22, read in part, .Spoke with [name withheld] BHT [behavioral health technician] regarding [POA] making multiple back-to-back calls to our facility to speak with [Resident #1] on the business line. This writer notified [name withheld] BHT that [POA] was the POA to this resident. It was stated to me the [POA] was not in the correct mental capacity to be anyone's POA. This writer has learned from [name withheld] BHT that [name of resident care facility] is a Level 2 Residential Center for people with behavior issues . A progress note, dated 07/21/22, read in part, .Call made to [name of residential care facility] regarding [POA], POA to this resident. Spoke with [name withheld], BHT and was notified that [POA] became very aggressive after loosing [sic] [pronoun omitted] phone privileges. It was also stated to me that [pronoun omitted] had thrown 2 personal cell phones in the trash due to that there were people in them telling [pronoun omitted] to do bad things. This writer was notified today that [POA] had been removed from the facility and would not be returning due to [pronoun omitted] extreme behaviors. [POA] was sent to CRC [Crisis Response Center] . A progress note, dated 07/21/22, read in part, .Call made to CRC (Crisis Response Center) and spoke with [name omitted] an employee, to locate [POA], POA of this resident. This writer was notified that the facility is an emergency room for people with behaviors and are only there for 24 hours. It was verified that [POA] had been a patient there but were unable to notify this writer where [pronoun omitted] had been relocated to . An abuse and neglect hotline submission, dated 07/21/22, read in part, .Unable to contact POA due to POA being placed in unknown psychiatric facility. Unable to meet [Resident #1] needs . A progress note, dated 07/21/22, documented the POA had moved into a friend's house and obtained a working phone. The progress note documented the POA was in a psychiatric hospital before moving in with a friend. An abuse and neglect hotline submission, dated 08/04/22, documented the facility had attempted without success to contact the POA for resident #1 to receive permission to transfer the resident to an acute care psychiatric hospital due to resident #1 physically assaulting another resident. A written notice of transfer/discharge, dated 08/26/22, documented an emergency transfer to an inpatient psychiatric hospital for resident #1. A progress note, dated 08/26/22, documented the resident was transferred to an inpatient geriatric psychiatric hospital due to multiple delusions and unsubstantiated allegations about other residents and staff. A progress note, dated 09/01/22, documented the POA had called and was provided the contact information for resident #1 at the inpatient psychiatric center. A fax cover sheet for The Notice of Involuntary Discharge, dated 09/02/22, read in part, .[Resident #1] was admitted to Betty Ann Nursing Center .Since [Resident #1's] admission, [Resident #1] has displayed inappropriate sexual behavior, been verbally and physically aggressive toward residents and staff which has led to several psychiatric hospitalization s. [Resident #1] refuses to follow Physicians [sic] orders putting [Resident #1] health in jeopardy also. Betty Ann Nursing Center has made numerous referrals to APS regarding [Resident #1's] behavior to no avail. [Resident #1's family member] and POA has been notified also regarding [Resident #1's] behavior and aggressive nature. Due to [Resident #1] continuing threat towards our residents and staff, Betty Ann Nursing Center has issued an emergency discharge as of today 09/02/22 .POA .is in Oklahoma and has notified our facility [POA] will find a home for both to live . The Notice of Involuntary Discharge, dated 09/02/22, documented the legal representative's address was in Tucson Arizona, the resident was currently in an inpatient psychiatric hospital, and would be discharged to the POA immediately upon discharge from the psychiatric hospital. The reason for discharge was for the resident's safety, or for the safety of other residents. The notice period was marked for emergency discharge mandated by the resident's health care needs and documented it was in accordance with the written orders and medical justification of the attending physician. The notice also marked the discharge was necessary for the physical safety of other residents as documented in the clinical record. The orientation for discharge read in part, .the facility has provided sufficient preparation and orientation to the resident to ensure safe and orderly transfer or discharge from the facility, as follows: Notify POA, & Bridges - Geri Psych facility in [NAME], Ok . The notice of involuntary discharge was signed by the administrator. A progress note, dated 09/02/22, documented the POA was notified of the resident's discharge from Betty Ann Nursing Center and the facility had requested an address to send the resident's belongings. A progress note, dated 09/06/22, documented the facility was in communication with the social service director at the inpatient psychiatric hospital caring for resident #1. The progress note read in part, .Notified [POA] regarding [Resident #1] discharge from our facility due to [name of psychiatric hospital] calling me here at the facility. According to the social worker at [name of psychiatric hospital] [POA] had secured a place for [POA and Resident #1] in Miami, OK. [POA] has of yet picked up [Resident #1] from hospital. When I spoke to [POA] regarding this [POA] stated [POA] had not made it to Oklahoma and was in Fayetteville waiting for another Greyhound to [NAME] . A Summary Order Overruling Involuntary Discharge, dated 09/07/22, read in part, .On September 7,2022, the Office of Administrative Hearings received a written appeal from [Resident #1] (Resident) to the Notice of Involuntary Transfer or Discharge of Resident issued by Betty Ann Nursing Center (Facility) on September 2, 2022 .The court finds an involuntary discharge hearing is not required because the Facility failed to comply with the provisions .regarding a written notice, as indicated below: The location to which the resident is transferred or discharged .Before a facility transfers or discharges a resident, the Facility must notify the Resident and the Resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman .A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand .The procedure for involuntary discharge .was not followed . The Summary Order Overruling Involuntary Discharge was signed by the administrative law judge and dated 09/07/22. A progress note, dated 09/07/22, read in part, .S/P discharge. This resident has stated to staff at Bridges that he does not wish to return to facility and wishes to join his [POA] in [NAME]. Facility has assisted in obtaining accommodations for this resident and his [POA] on this date . A progress note, dated 09/07/22, documented resident #1 returned to Betty Ann Nursing Center. A progress note, dated 09/08/22 at 9:43 a.m., documented the POA was at the facility to visit the resident and the resident would leave with the POA. A physician's progress note, dated 09/08/22, documented the resident was seen via telemedicine. The progress note documented the resident was safe to live in the community with the POA, who agreed to be responsible for the resident's daily care. A typed statement, dated 09/08/22, documented the resident had returned from a psychiatric hospitalization on [DATE] and wished to leave with the POA. The statement documented the physician was notified and agreed with the discharge. The statement documented the POA assured the facility they could provide care for the resident. The statement was signed by the POA and resident. A progress note, dated 09/08/22 at 12:56 p.m., documented the POA and resident #1 were transported across state lines to a motel in Missouri. The progress note read in part, .pt transported x2 supportive staff via van to Budget Inn in Neosho, Mo with [POA]. Personal property and medications released to [POA] and education provided by ADON with verbalized understanding and demonstration performed . On 09/12/22 at 5:02 p.m., an interview was conducted with the social service director for the inpatient psychiatric hospital which treated resident #1. The social service director stated Betty Ann Nursing Center had requested the hospital find new placement for the resident and the hospital attempted to find new placement but was unsuccessful. The social service director stated Betty Ann Nursing Center refused to take the resident back and issued a Notice of Involuntary Discharge. The social service director stated the facility informed them the resident's POA was on their way to Oklahoma. The social service director stated Betty Ann Nursing Center recommended the psychiatric hospital discharge the resident directly into the care of the POA. The social service director stated they informed the administration at Betty Ann Nursing Center the resident's POA was homeless and could not care for the resident and as such the psychiatric hospital would not discharge the resident to the care of the POA. The social service director stated the administration at Betty Ann Nursing Center continued to refuse the resident's transfer back so the social service director contacted the corporate office for Betty Ann Nursing Center and spoke with a corporate level administrator who reiterated the facility was not accepting the resident's return to Betty Ann Nursing Center and would bodily remove the resident and their belongings if they were to return. The social service director stated they informed the corporate administrator the hospital planned to file a complaint with the state health department. The social service director stated the corporate administrator said they would gladly accept the deficiency. On 09/13/22 at 3:40 p.m., an interview was conducted with the POA for Resident #1. The POA stated over the last year, the facility called many times and threatening to discharge the resident and demand they come and pick the resident up from the facility. The POA stated this time when the facility called, they informed the POA they were not re-admitting resident #1 and the POA needed to come and get them from the hospital. The POA stated when they received the call from the facility denying resident #1's re-admission from the psychiatric hospital, they immediately left for Oklahoma. The POA stated they felt threatened by the facility administration. The POA stated the facility informed them resident #1 would not be transferred back to the facility and the facility planned to have the hospital discharge resident #1 to the street unless the POA immediately came to Oklahoma to get the resident. The POA stated they had no place to live, no car, and no means to get to Oklahoma. The POA was homeless and staying with a friend while awaiting placement at a shelter in Tucson, AZ. The POA stated they grabbed what little money they had from their social security disability check, bought a bus ticket, and left all their belongings in Arizona. The POA stated they were able to make it as far as [NAME] Missouri by bus before their money was exhausted and they had to hitchhike the remaining distance to Grove Oklahoma. The POA stated they were not prepared to take on the responsibility of their family member's care, they had no money, no home, no transportation, and only a vague plan to go to Tulsa to find work and housing. The POA stated they came to Grove to visit their family member and ensure they were not discharged to the streets. The POA stated with no money and only the clothes on their back, they had no intention of taking the resident with them. The POA stated the DON met them outside and informed them they were discharging the resident into their care immediately. The POA stated the administration brought the POA and resident #1 into their office and asked the resident if they wished to leave with the POA. The POA stated the resident responded that when the POA had a stable home, they would love to live with them. The POA stated the facility administrator boasted they were going to make the resident's dream come true immediately. The POA stated the administration had found a cheap place for them to stay in Neosho Missouri. The POA stated the administration had made arrangements at the Budget Inn in Neosho, Missouri for their stay and provided them transportation to the motel and the $260.00 to pay for the first week's stay. The POA stated when the clerk at the Budget Inn would not accept payment for more than a week at a time, the facility staff gave the POA an additional $740.00 in cash. The POA stated their plan when coming to Oklahoma had been to ensure resident #1 was safe and then go to Tulsa to look for work and housing before resident #1 moved in with them. The POA stated after seeing how the administration was forcing the discharge, they were afraid the facility would discharge resident #1 before they had a chance to find a home. The POA stated they asked the facility to take them to Tulsa but was told no by the administration, which stated they had already made the arrangements in Neosho. The POA stated they were not adequately prepared by the facility to care for Resident #1. The POA stated the room which was provided was not handicapped accessible, having a step to cross to even get into the room. The POA stated they were not comfortable giving the medications as instructed and felt they would harm the resident. They stated as an example, they were instructed to give the resident 15 tablets of [MEDICATION(S)] 500mg [7500mg total], three times a day and they were not comfortable with giving that much medication. The POA stated when they questioned the facility about the dosage, they told the POA the resident had been taking that much [MEDICATION(S)] in the facility and had been fine. The POA stated they were given the resident's list of medications but were not instructed on what the medications were for or what to monitor. They further stated the facility did not do a good job with providing instructions for care and Resident #1 had been seen by emergency personnel. The POA stated they did not have home health or any other community support and no longer had Medicaid since the resident now resided in Missouri and not Oklahoma. The POA stated they had no way to get to appointments and were miles away from grocery stores, pharmacies, and restaurants. The POA stated they themselves had recently been hospitalized in a psychiatric hospital for a nervous breakdown, were exhausted from taking care of all the resident's needs, and needed a nurse to come in and help with the resident's care. On 09/15/22 at 12:00 p.m., the social service director stated over the last year they had tried to find placement at different nursing homes all over Oklahoma but were denied, with most stating their facility was unable to meet the resident's needs. The social service director stated they provided education on the resident's medications and color coded the medications to show when to give each one. They denied setting up community services such as home health or assisting in finding a new primary care physician for the resident. The social service director stated other than educating the POA on the resident's medications, they were not involved in the resident's discharge. On 09/15/22 at 12:15 p.m., an interview was conducted with the assistant director of nursing. The ADON stated they did not participate in the resident's discharge but did deliver to the POA at the motel room the resident's insulin, some insulin syringes, and $60.00 in cash the resident had left in an activity fund. On 09/15/22 at 12:30 p.m., an interview was conducted with director of nursing #1. The DON stated the resident hired an attorney to appoint the POA. The DON stated the resident thought if the facility needed to send the resident to the hospital, the POA could stop it. DON #1 stated the facility was losing staff because of the resident's behaviors, including calling police on staff. DON #1 stated the administrator informed them they were going to discharge the resident while the POA was in Oklahoma and the resident was in the psychiatric hospital. The DON stated they did not write the involuntary discharge personally, having never written one before, but did email the form to the psychiatric hospital. DON #1 stated they thought the POA and resident would do fine in the community but admitted they did not know the area nor had seen the motel. The DON stated the POA and resident wanted to stay in Neosho for three weeks and, after they received their disability checks, take a flight to California. DON #1 stated Resident #1 had stated he wanted to move to California. DON #1 stated the POA and resident were transported to Neosho using a sister facility's van and driver. The DON stated the administrator accompanied the POA and resident to Neosho for the discharge. DON #1 stated the POA had contacted the facility just the day before and asked about getting more needles to administer insulin. The DON informed the POA a pharmacy would probably be the best place to find needles. On 09/15/22 at 12:50 p.m., the administrator stated facility staff threatened to walk out if Resident #1 returned to the facility. The administrator stated they had the choice to re-admit Resident #1 and risk losing the staff who provided care to all the residents or refuse to re-admit Resident #1 and keep their staff. The administrator stated they agreed to re-admit resident #1 to Betty Ann Nursing Center when the facility learned the POA was coming to visit the resident because the psychiatric hospital refused to discharge Resident #1 directly to the POA. The administrator stated when the POA arrived, Resident #1 stated they wanted to go live with them. The administrator stated the facility helped facilitate the resident's desire to live with their POA by providing them a motel room. The administrator stated they found a motel in Neosho, Missouri, paid $267.00 for one week's stay, and gave the POA another $733.00 in cash to total $1000.00. The administrator stated the facility had provided a list of community resources but did not attempt to set up services. The hospital progress note, dated 09/18/22, documented the resident was treated in the emergency room for an elevated blood sugar. On 09/20/22 at 4:12 p.m., the POA stated they contacted an ambulance on 09/12/22 for low blood sugar and again on 09/18/22 for an elevated blood sugar. The hospital progress note, dated 09/20/22, documented the resident was treated in the emergency room for a fall with head trauma; the resident had fallen when attempting to exit the bathtub and hit their head on the toilet.

Based on interview and record review, the facility failed to ensure a resident was discharged to the community with necessary support and services for one (#1) of three sampled residents. Resident #1 was discharged to a hotel with their POA without setting up community services and resources. Resident #1 was taken by ambulance three times; once for low blood sugar, once for a fall, and once for a high blood sugar; after being improperly discharged into the community. The fall resulted in the resident sustaining head trauma and being treated at the hospital. The facility census and condition identified 51 residents. Findings: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 12/24/21, documented the resident entered the facility from a psychiatric hospital, was cognitively intact and was feeling down, depressed, or hopeless. The assessment documented the resident exhibited verbal behavioral symptoms directed toward others. The assessment documented the resident required limited to extensive assistance with activities of daily living. A notarized letter from the attending physician, dated 01/14/22, documented the resident was mentally and physically incapacitated. A notarized letter from physician #2, dated 01/14/22, documented the resident was mentally and physically incapacitated. An abuse and neglect hotline submission, dated 03/22/22, read in part, .This resident frequently calls [POA] that lives out of state and the facility has been notified by another family member that this is very concerned [sic] that's resident's [POA] is not capable of care for this resident's needs . The quarterly assessment, dated 06/26/22, documented the resident was cognitively intact, had fluctuating changes in mental status (inattention, disorganized thinking, altered level of consciousness), had physical and verbal behavioral symptoms directed toward others, and rejected care. The assessment documented the resident required supervision to limited assistance with most activities of daily living. A progress note, dated 07/14/22, read in part, .Spoke with [name withheld] BHT [behavioral health technician] regarding [POA] making multiple back-to-back calls to our facility to speak with [Resident #1] on the business line. This writer notified [name withheld] BHT that [POA] was the POA to this resident. It was stated to me the [POA] was not in the correct mental capacity to be anyone's POA. This writer has learned from [name withheld] BHT that [name of resident care facility] is a Level 2 Residential Center for people with behavior issues . A progress note, dated 07/21/22, read in part, .Call made to [name of residential care facility] regarding [POA], POA to this resident. Spoke with [name withheld], BHT and was notified that [POA] became very aggressive after loosing [sic] [pronoun omitted] phone privileges. It was also stated to me that [pronoun omitted] had thrown 2 personal cell phones in the trash due to that there were people in them telling [pronoun omitted] to do bad things. This writer was notified today that [POA] had been removed from the facility and would not be returning due to [pronoun omitted] extreme behaviors. [POA] was sent to CRC [Crisis Response Center] . A progress note, dated 07/21/22, read in part, .Call made to CRC (Crisis Response Center) and spoke with [name omitted] an employee, to locate [POA], POA of this resident. This writer was notified that the facility is an emergency room for people with behaviors and are only there for 24 hours. It was verified that [POA] had been a patient there but were unable to notify this writer where [pronoun omitted] had been relocated to . An abuse and neglect hotline submission, dated 07/21/22, read in part, .Unable to contact POA due to POA being placed in unknown psychiatric facility. Unable to meet [Resident #1] needs . A progress note, dated 08/26/22, documented the resident was transferred to an inpatient geriatric psychiatric hospital due to multiple delusions and unsubstantiated allegations about other residents and staff. A fax cover sheet for The Notice of Involuntary Discharge, dated 09/02/22, read in part, .[Resident #1] was admitted to Betty Ann Nursing Center .Since [Resident #1's] admission, [Resident #1] has displayed inappropriate sexual behavior, been verbally and physically aggressive toward residents and staff which has led to several psychiatric hospitalization s. [Resident #1] refuses to follow Physicians [sic] orders putting [Resident #1] health in jeopardy also. Betty Ann Nursing Center has made numerous referrals to APS regarding [Resident #1's] behavior to no avail. [POA] and POA has been notified also regarding [Resident #1's] behavior and aggressive nature. Due to [Resident #1] continuing threat towards our residents and staff, Betty Ann Nursing Center has issued an emergency discharge as of today 09/02/22 .POA .is in Oklahoma and has notified our facility [POA] will find a home for both to live . The Notice of Involuntary Discharge, dated 09/02/22, documented the legal representative's address was in Tucson Arizona, the resident was currently in an inpatient psychiatric hospital, and would be discharged to the POA immediately upon discharge from the psychiatric hospital. The reason for discharge was for the resident's safety, or for the safety of other residents. The notice period was marked for emergency discharge mandated by the resident's health care needs and documented it was in accordance with the written orders and medical justification of the attending physician. The notice also marked the discharge was necessary for the physical safety of other residents as documented in the clinical record. The orientation for discharge read in part, .the facility has provided sufficient preparation and orientation to the resident to ensure safe and orderly transfer or discharge from the facility, as follows: Notify POA, & Bridges - Geri Psych facility in [NAME], Ok . The notice of involuntary discharge was signed by the administrator. A progress note, dated 09/02/22, documented the POA was notified of the resident's discharge from Betty Ann Nursing Center and the facility had requested an address to send the resident's belongings. A progress note, dated 09/06/22, documented the facility was in communication with the social service director at the inpatient psychiatric hospital caring for resident #1. The progress note read in part, .Notified [POA] regarding [Resident #1] discharge from our facility due to [name of psychiatric hospital] calling me here at the facility. According to the social worker at [name of psychiatric hospital] [POA] had secured a place for [POA and Resident #1] in Miami, OK. [POA] has of yet picked up [Resident #1] from hospital. When I spoke to [POA] regarding this [POA] stated [POA] had not made it to Oklahoma and was in Fayetteville waiting for another Greyhound to [NAME] . A Summary Order Overruling Involuntary Discharge, dated 09/07/22, read in part, .On September 7,2022, the Office of Administrative Hearings received a written appeal from [Resident #1] (Resident) to the Notice of Involuntary Transfer or Discharge of Resident issued by Betty Ann Nursing Center (Facility) on September 2, 2022 .The court finds an involuntary discharge hearing is not required because the Facility failed to comply with the provisions .regarding a written notice, as indicated below: The location to which the resident is transferred or discharged .Before a facility transfers or discharges a resident, the Facility must notify the Resident and the Resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman .A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand .The procedure for involuntary discharge .was not followed . The Summary Order Overruling Involuntary Discharge was signed by the administrative law judge and dated 09/07/22. A progress note, dated 09/07/22, read in part, .S/P discharge. This resident has stated to staff at Bridges that he does not wish to return to facility and wishes to join his [POA] in [NAME]. Facility has assisted in obtaining accommodations for this resident and his [POA] on this date . A progress note, dated 09/07/22, documented resident #1 returned to Betty Ann Nursing Center. A progress note, dated 09/08/22 at 9:43 a.m., documented the POA was at the facility to visit the resident and the resident would leave with the POA. A typed statement, dated 09/08/22, documented the resident had returned from a psychiatric hospitalization on [DATE] and wished to leave with the POA. The statement documented the physician was notified and agreed with the discharge. The statement documented the POA assured the facility they could provide care for the resident. The statement was signed by the POA and resident. A progress note, dated 09/08/22 at 12:56 p.m., documented the POA and resident #1 were transported across state lines to a motel in Missouri. The progress note read in part, .pt transported x2 supportive staff via van to Budget Inn in Neosho, Mo with [POA]. Personal property and medications released to [POA] and education provided by ADON with verbalized understanding and demonstration performed . On 09/12/22 at 5:02 p.m., the social service director for the inpatient psychiatric hospital which treated resident #1 stated Betty Ann Nursing Center refused to take the resident back and issued a Notice of Involuntary Discharge. The social service director stated the facility informed them the resident's POA was on their way to Oklahoma. The social service director stated Betty Ann Nursing Center recommended the psychiatric hospital discharge the resident directly into the care of the POA. The social service director stated they informed the administration at Betty Ann Nursing Center the resident's POA was homeless and could not care for the resident and as such the psychiatric hospital would not discharge the resident to the care of the POA. The social service director stated the administration at Betty Ann Nursing Center continued to refuse the resident's transfer back so the social service director contacted the corporate office for Betty Ann Nursing Center and spoke with a corporate level administrator who reiterated the facility was not accepting the resident's return to Betty Ann Nursing Center and would bodily remove the resident and their belongings if they were to return. The social service director stated they informed the corporate administrator the hospital planned to file a complaint with the state health department. The social service director stated the corporate administrator said they would gladly accept the deficiency. On 09/13/22 at 3:40 p.m., the POA stated over the last year, the facility called many times and threatening to discharge the resident and demand they come and pick the resident up from the facility. The POA stated this time when the facility called, they informed the POA they were not re-admitting resident #1 and the POA needed to come and get them from the hospital. The POA stated when they received the call from the facility denying resident #1's re-admission from the psychiatric hospital, they immediately left for Oklahoma. The POA stated they felt threatened by the facility administration. The POA stated the facility informed them resident #1 would not be transferred back to the facility and the facility planned to have the hospital discharge resident #1 to the street unless the POA immediately came to Oklahoma to get the resident. The POA stated they had no place to live, no car, and no means to get to Oklahoma. The POA was homeless and staying with a friend while awaiting placement at a shelter in Tucson, AZ. The POA stated they grabbed what little money they had from their social security disability check, bought a bus ticket, and left all their belongings in Arizona. The POA stated they were able to make it as far as [NAME] Missouri by bus before their money was exhausted and they had to hitchhike the remaining distance to Grove Oklahoma. The POA stated they were not prepared to take on the responsibility of their family member's care, they had no money, no home, no transportation, and only a vague plan to go to Tulsa to find work and housing. The POA stated they came to Grove to visit their family member and had no intention of taking the resident with them. The POA stated the DON met them outside and informed them they were discharging the resident into their care immediately. The POA stated the administration brought the POA and resident #1 into their office and asked the resident if they wished to leave with the POA. The POA stated the resident responded that when the POA had a stable home, they would love to live with them. The POA stated the facility administrator boasted they were going to make the resident's dream come true immediately. The POA stated the administration had found a cheap place for them to stay in Neosho Missouri. The POA stated the administration had made arrangements at the Budget Inn in Neosho, Missouri for their stay and provided them transportation to the motel and the $260.00 to pay for the first week's stay. The POA stated when the clerk at the Budget Inn would not accept payment for more than a week at a time, the facility staff gave the POA an additional $740.00 in cash. The POA stated their plan when coming to Oklahoma had been to ensure resident #1 was safe and then go to Tulsa to look for work and housing before resident #1 moved in with them. The POA stated after seeing how the administration was forcing the discharge, they were afraid the facility would discharge resident #1 before they had a chance to find a home. The POA stated they asked the facility to take them to Tulsa but was told no by the administration, which stated they had already made the arrangements in Neosho. The POA stated they were not adequately prepared by the facility to care for Resident #1. The POA stated the room which was provided was not handicapped accessible, having a step to cross to even get into the room. The POA stated they were not comfortable giving the medications as instructed and felt they would harm the resident. They stated as an example, they were instructed to give the resident 15 tablets of [MEDICATION(S)] 500mg [7500mg total], three times a day and they were not comfortable with giving that much medication. The POA stated when they questioned the facility about the dosage, they told the POA the resident had been taking that much [MEDICATION(S)] in the facility and had been fine. The POA stated they were given the resident's list of medications but were not instructed on what the medications were for or what to monitor. They further stated the facility did not do a good job with providing instructions for care and Resident #1 had been seen by emergency personnel. The POA stated they did not have home health or any other community support and no longer had Medicaid since the resident now resided in Missouri and not Oklahoma. The POA stated they had no way to get to appointments and were miles away from grocery stores, pharmacies, and restaurants. The POA stated they themselves had recently been hospitalized in a psychiatric hospital for a nervous breakdown, were exhausted from taking care of all the resident's needs, and needed a nurse to come in and help with the resident's care. On 09/15/22 at 12:00 p.m., the social service director stated they provided education on the resident's medications and color coded the medications to show when to give each one. They denied setting up community services such as home health or assisting in finding a new primary care physician for the resident. The social service director stated other than educating the POA on the resident's medications, they were not involved in the resident's discharge. On 09/15/22 at 12:15 p.m., the ADON stated they did not participate in the resident's discharge. On 09/15/22 at 12:30 p.m., DON #1 stated the administrator informed them they were going to discharge the resident while the POA was in Oklahoma and the resident was in the psychiatric hospital. The DON stated they did not write the involuntary discharge personally, having never written one before, but did email the form to the psychiatric hospital. DON #1 stated the POA and resident were transported to Neosho using a sister facility's van and driver. The DON stated the administrator accompanied the POA and resident to Neosho for the discharge. DON #1 stated the POA had contacted the facility just the day before and asked about getting more needles to administer insulin. The DON informed the POA a pharmacy would probably be the best place to find needles. On 09/15/22 at 12:50 p.m., the administrator stated facility staff threatened to walk out if Resident #1 returned to the facility. The administrator stated they had the choice to re-admit Resident #1 and risk losing the staff who provided care to all the residents or refuse to re-admit Resident #1 and keep their staff. The administrator stated they agreed to re-admit resident #1 to Betty Ann Nursing Center when the facility learned the POA was coming to visit the resident because the psychiatric hospital refused to discharge resident #1 directly to the POA. The administrator stated when the POA arrived, Resident #1 stated they wanted to go live with them. The administrator stated the facility helped facilitate the resident's desire to live with their POA by providing them a motel room. The administrator stated they found a motel in Neosho, Missouri, paid $267.00 for one week's stay, and gave the POA another $733.00 in cash to total $1000.00. The administrator stated the facility had provided a list of community resources but did not attempt to set up services. The hospital progress note, dated 09/18/22, documented the resident was treated in the emergency room for an elevated blood sugar. On 09/20/22 at 4:12 p.m., the POA stated they contacted an ambulance on 09/12/22 for low blood sugar and again on 09/18/22 for an elevated blood sugar for resident #1. The hospital progress note, dated 09/20/22, documented the resident was treated in the emergency room for a fall with head trauma; the resident had fallen while attempting to exit the bathtub and hit their head on the toilet.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls which resulted in actual harm for two (#2 and #5) of ten sampled residents who had experienced falls. ~Resident #2 experienced eight falls in three months. The resident sustained [REDACTED]. The resident was sent to the emergency roiagnom on both occaisions and required sutures for the laceration and was in ICU with mental status changes with the second injury. ~Resident #5 experienced 13 falls in six months. The resident sustained [REDACTED]. The resident was sent to the emergency room five times, recieved sutures to a head laceration once and then steristips when the laceration was reopened during a subsequent fall. The facility identified 34 residents who were at high risk for falls. Findings: An undated fall policy documented, .When a resident is found on the floor, the facility is obligated to investigate and try to determine how he or she got there, and to put into place an intervention to prevent this from happening again.Interdisciplinary Falls Committee.The falls committee meets daily and weekly. The falls with immediate interventions are reviewed daily in the morning meeting.the fall is discussed, the care plan is reviewed and recommendations for safety interventions are made.The care plan is updated in the meetings (morning meeting and fall committee).Steps to follow when a fall occurs.complete falls investigation to determine cause.Immediate team meeting with current staff to determine intervention to prevent further falls.Establish new interventions and place them on care plan.Implement interventions on care plan.Key fall interventions.Do not depend on bed and chair alarms to stop the resident from falling by the time you hear the alarm and reach the resident- the resident is on the floor.Activity department to set up routine activity programs at times of greatest need.Evaluate tracking and trending, evaluate time of day and location of falls, and evaluate staffing at different times of the day. Put a plan of action in place to correct issues.Revise each care plan after each fall with a new intervention. 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/02/14, documented the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent in most activities of daily living and experienced no falls since admission/entry or prior assessment. A risk for falls care plan, dated 12/16/14, documented, Focus: Falls: .at risk for falls d/t inability to transfer self safely, daily usage of psychotropic medication, non-ambulatory status, past hx of falls.Goal: .will be free of serious injury r/t falls.Interventions: .anticipate and meet (resident #5) needs.check q 2hrs and prn for toileting/hygiene needs.assist with transfer needs at all times; two person assistance prn. A nurse's note, dated 12/29/14, documented, Resident fell forward out of w/c hitting his (left) temple against the floor. Sm hematoma noted.transport to ER for eval.returned to facility.treated for [REDACTED]. The fall care plan updated 12/29/14, documented, fell forward hitting left temple neuro checks initiated. There were no new fall interventions addressed or implemented to prevent further falls. A nurse's note, dated 01/05/15, documented, CNA reported that she was attempting to move resident in his w/c.res grabbed the pole near the nurse's station.resident went forward and fell to the floor before she could catch him.Res has a very large hematoma to left temple are purple area in center.transported to ER.returned to facility.orders rec'd.apply ice pack to (left) temple hematoma prn. The fall care plan updated 01/05/15, documented, fell to floor hematoma to left temple-sent to ER & returned neuro initiated. There were no new fall interventions addressed or implemented to prevent further falls. A nurse's note, dated 01/06/15, documented, Res rolled out of his w/c. Has bruise to (left) knee.he also has a skin tear to his (right) & (left) elbow area. An incident/accident report, dated 01/06/15, documented, Res fell forward out of w/c has bruise on (Left) knee. No other injuries noted.steps taken to prevent recurrence: (blank). The fall care plan updated 01/06/15, documented, rolled out of w/c bruise noted. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 01/14/15, documented, Res was observed on the floor leaning against the door frame of the door near nurses' station that goes outside. Res was assessed for injuries no injuries noted- Res MAEW.steps taken to prevent recurrence: (blank). The fall care plan updated 01/14/15, documented, Observed on floor, no injury noted. There were no new fall interventions addressed or implemented to prevent further falls. The fall care plan updated on 01/22/14, documented, May have bed in low position with mat on the floor. A fall risk assessment, dated 02/07/15, documented the resident had a score of 11. A score of 10 or above deemed the resident at high risk for falls. A quarterly assessment, dated 03/02/15, documented the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent in most activities of daily living and experienced two or more falls with no injury and two or more falls with injury (except major) since admission/entry or prior assessment. An incident/accident report, dated 03/13/15, documented, Son visiting after son left CNA stated resident was on the floor - resident laying on (right) side - skin tear to (left) hand.steps taken to prevent recurrence: (blank). The fall care plan updated 03/13/15, documented, Son visiting after son left CNA stated res was on the floor-laying on (right) side-skin tear (left) hand. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 03/22/15, documented, Resident observed lying on floor on (left) side, 1.3 x 1.3 abrasion noted to (left) forehead, assisted back to wheelchair resident in front of back door.steps taken to prevent recurrence: resident to be redirected from back door neuro checks started. The fall care plan updated 03/22/15, documented, Observed lying on floor of (left) side 1.3x1.3 abrasion noted to (left)forehead. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 04/02/15, documented, Resident fell out of w/c and hit forehead on (left) side above eye. Resident has abrasion to (left) forehead and skin tear to (left) hand.transfer to ER.corrective measures implemented to prevent recurrence: pen alarm to be placed while resident is in w/c et pressure alarm while in recliner and/or bed. Staff will attempt to redirect when grabbing @ hallucination of cattle panel or cows/goats/dogs/sheep. The fall care plan was not updated with the fall or new interventions to prevent recurrence. An incident/accident report, dated 04/05/15, documented, Res was leaning forward to pick something off the floor & fell forward resting head on the recliner in front of him, Res slid to floor.steps taken to prevent recurrence: (blank). The fall care plan updated 04/05/15, documented, Res fell forward.slid to floor.no injuries. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 04/15/15, documented, Res leaned forward in w/c and fell to floor, reopened small area on scabed(sic) area on left hand.steps taken to prevent recurrence: careplanned pen alarm will be placed. The fall care plan updated 04/15/15, documented, Res leaned forward fell to floor reopened skin tear to hand no further injuries. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 04/27/15, documented, Res leaned forward in w/c and slid out onto left side. Skin tear with bruising to left elbow.steps taken to prevent recurrence: will continue to use alarms. The fall care plan updated 04/27/15, documented, Res leaned forward in w/c slid out onto (left) side skin tear - bruising to (left) elbow. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 05/04/15, documented, Rolled out of bed onto safety mat, positioned on hands & knees. (No) injuries noted.steps taken to prevent recurrence: low bed c safety mat. The fall care plan updated 05/04/15, documented, Rolled out of bed onto safety mat, (no) injuries. There were no new fall interventions addressed or implemented to prevent further falls. A fall risk assessment, dated 05/05/15, documented the resident had a score of 11. A score of 10 or above deemed the resident at high risk for falls. A nurse's note, dated 05/10/15, documented, .resident was leaning forward and pushed c legs and landed on floor. Abrasion noted 0.2x0.2x0.2. Abrasion to (left)outer brow. The fall care plan was not updated with the fall or new interventions to prevent recurrence. An incident/accident report, dated 05/26/15, documented, CNA was propelling resident to solarium when resident leaned forward & fell out of w/c before CNA could catch him. Resident struck (left) side of head against floor. Laceration to (left) eyebrow.sent to hospital ER for eval & tx.steps taken to prevent recurrence: secure hand on shoulder during transport in w/c. A nurse's note, dated 05/26/15, documented, Returned to facility.6 sutures to (left) eyebrow c bruising noted. A fall investigation, dated 05/26/15, documented no new interventions were put into place to prevent repeated occurrence. The fall care plan updated 05/26/15, documented, fall laceration to (left) eyebrow 6 sutures. There were no new fall interventions addressed or implemented to prevent further falls. An incident/accident report, dated 06/03/15, documented, Resident leaned forward out of wheelchair so quick staff could not get to him fast enough to prevent fall. Laceration to left eyebrow was busted open again.steps taken to prevent recurrence: (blank). A nurse's note, dated 06/03/15, documented, Returned to facility.steristips to (left) brow noted. The fall care plan updated 06/03/15, documented, leaned forward & fell out of w/c hit (left) eyebrow. There were no new fall interventions addressed or implemented to prevent further falls. On 06/15/15 at 11:20 a.m. and throughout the survey the resident was observed up in a recliner near the nurse's station or in a wheelchair at meals. On 06/16/15 at 4:21 p.m., the administrator was asked about the falls. She stated, We QA'd the falls in March, I believe, and we realized we had a problem.We showed a reduction in falls in April. We have a tracking and trending report. We added another aide on the second shift. That was where we discovered the most falls. On 06/17/15 at 11:25 a.m., the restorative aide was asked if the resident was receiving restorative therapy. She stated, I have never had (name deleted) on restorative. He's on hospice. At 3:50 p.m., the care plan coordinator was asked if the care plan was updated with new interventions after each fall. She stated, The nurses are to document on the care plan after a fall. If the fall care plan is not updated, I check the nures' notes and the incident report. If no intervention there, then I do not update the care plan with new interventions. At 4:13 p.m., the DON was asked if investigations had been done after each fall to discover the root cause. She stated, Yes, I have them in my office. The DON was asked who updated the care plan interventions after each fall. The DON stated, The nurses should be putting them on the care plan. At 4:41 p.m., the DON provided one fall investigation for 05/26/15. The DON stated, We started fall investigations the first of May. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, dated 01/05/14, documented, Focus: Risk for fall d/t unsteady balance/gait, daily usage of behavioral medications, hx of falls.uses w/c for locomotion. Goal:.will be free from serious injury r/t falls. Interventions:.check for placement of w/c or chair, prior to sitting down.encourage rest periods as needed.Keep call light within reach to call for help. A fall risk assessment, dated 02/09/15, documented the resident had a score of seven. A score of 10 or above deems the resident at a high risk for falls. A quarterly assessment, dated 03/22/15, documented the resident had a BIMS score of 11. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers/ambulation with one person assistance, was not steady moving from seated to standing, moving from on and off toilet, and had experienced two non-injury falls, one fall with injury and one with major injury. An incident/accident report, dated 04/01/15, documented, .Res was observed on his knees leaning against his bed, denies injury none noted neuros started. The incident report had no documentation of interventions to prevent recurrence. The fall care plan, updated 04/01/15, documented, .On 4/1/15 Observed on his knees leaning against his bed, neuro initiated, (no) injury noted. There was no new interventions documented to prevent further falls. An incident/accident report, dated 04/06/15, documented, .Res was observed lying on the floor near his bed. Res stated he was trying to get into his w/c, Res denied hitting his head Neuros started. The incident report had no documentation of interventions to prevent recurrence. The fall care plan, updated 04/06/15, documented, .observed lying on the floor near his bed trying to get to his w/c. Neuros started, (no) injury noted. There was no new interventions documented to prevent further falls. An incident/accident report, dated 04/15/15, documented, .Res was observed lying on the floor in his room. Res denies hitting head, denies pain. The incident report had no documentation of interventions to prevent recurrence. The fall care plan, updated 4/15/15, documented, .Res observed lying on floor no injury. There was no new interventions documented to prevent further falls. An incident/accident report, dated 04/21/15, documented, .Res observed sitting on the floor in front of w/c in his rm. The intervention to prevent further falls documented, Pressure alarm placed in w/c. low bed (with) safety mat. The fall care plan, updated 04/21/15, documented, fell (no) injuries.pressure alarm in w/c (and) bed. Low bed (with) safety mat. A physician's progress note, dated 04/28/15, documented, .Recheck fall - pt fell out of bed sat. No apparent (sic) injuries - fall mat in place (with) low bed. A fall risk assessment, dated 05/05/15, documented the resident had a score of 10. A score of 10 or above deemed the resident at high risk for falls. An incident/accident report, dated 05/07/15, documented, .Res was observed sitting on the safety mat beside his bed. Res stated that he slid self to floor. Res denies hitting head (and) denies injury Neuros started. The incident report had no documentation of interventions to prevent recurrence. A fall investigation, dated 05/07/15, documented no new interventions were put into place to prevent repeated occurrence. The fall care plan, updated 05/07/15, documented, Res observed on floor-slid to floor; denies hitting head. There were no new interventions documented to prevent further falls. A significant change assessment, dated 05/19/15, documented the resident had a BIMS score of 08. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with transfers/ambulation with one person assistance, was not steady moving from seated to standing, moving from on and off toilet, and had experienced two non-injury falls, and one fall with major injury. An incident/accident report, dated 05/28/15, documented, .Resident was bleeding from forehead and was crawling on floor stated he fell out of his wc. The intervention to prevent further falls documented, .alarm (and) pressure alarm in chair. The fall care plan was not updated with the fall or new interventions to prevent recurrence. The licensed nurses progress notes, dated 05/28/15, documented, Resident was found crawling on floor in his room, pt had laceration to Rt eyebrow, activated EMS.EMS transported Resident to (name deleted) hospital for tx (and) eval.Resident received sutures to Rt eyebrow. An incident/accident report, dated 06/11/15, documented, .Resident was bleeding observed lying in the doorway of his room, Back of pt's head was bleeding and swollen.Activated 911 so pt could be evaluated.Resident is 73 y/o male with dementia.Pt has been taught over and over not to get up without assistance but pt is very forgetful (and) he does it anyway.Resident sent to ER, returned to this facility after 2 hours.on 6/11/15 resident was unresponsive transferred back to (hospital deleted) ER.was admitted to ICU for [REDACTED]. Resident.to have.alarm while in w/c (and) pressure alarm while in bed. A fall investigation, dated 06/11/15, documented no new interventions were put into place to prevent repeated occurrence. The fall care plan was not updated with the fall or new interventions to prevent recurrence. An incident/accident report, dated 06/13/15, documented, .Res was observed lying on Rt side on the floor in the solarium.No s/s of injury.alarm placed on res. The fall care plan, updated 06/13/15, documented, .res fell No injuries noted. There were no new interventions documented to prevent further falls. On 06/15/15 at 11:10 a.m. and throughout the survey the resident was observed to be up in his wheelchair or in bed. An alarm was observed in place to the resident's left shoulder while up in the wheelchair. On 06/16/15 at 10:45 a.m., the resident was observed in bed trying to sit up unassisted. The resident's call light was observed laying at the foot of the bed, not in the resident's reach, and there was no bedside mat on the floor next to the bed. The resident stated he wanted to get out of bed. At 11:50 a.m., CNA #1 was asked what type of interventions were used to prevent the resident from falling. She stated, An alarm was used when he is up in the wheelchair, bed is to be kept in the lowest position, a pressure alarm was on the bed. The CNA was asked if the resident was able to use his call light. The CNA stated, He occasionally uses the call light but we usually need to anticipate his needs. On 06/16/15 at 4:21 p.m., the administrator was asked about the falls. The administrator stated, We QA'd the falls in March, I believe, and we realized we had a problem. We showed a reduction in falls in April. We have a tracking and trending report. We added another aide on the second shift. That was where we discovered the most falls. On 06/17/15 at 3:50 p.m., the care plan coordinator was asked if the care plan was updated with new interventions after each fall. The coordinator stated, The nurses are to document on the care plan after a fall. If the fall care plan is not updated, I check the nurses' notes and the incident report. If no intervention there, then I do not update the care plan with new interventions. At 4:13 p.m., the DON was asked if investigations had been done after each fall to discover the root cause. The DON stated, Yes, I have them in my office. The DON was asked who updated the care plan interventions after each fall. The DON stated, The Nurses should be putting them on the care plan. The DON was asked if the interventions had prevented the resident from injuries. The DON did not respond. At 4:41 p.m., the DON provided two fall investigations for the resident, one for a fall on 05/07/15, and one for 06/11/15. The DON stated, We started fall investigations the first of May.